Optic disc drusen: understanding an old problem from a new perspective

Optic disc drusen: Dystrophic calcification, a potential target for treatment

Optic disc drusen (ODD) are calcified, acellular bodies, seen in the optic nerve head of up to 2% of the population. Although seldomly affecting visual acuity, visual field defects are common, and severe, ischemic complications causing irreversible vision loss are known to occur. Different treatment strategies for ODD have been explored, but so far without success. This review focuses on the unique, calcified property of ODD, describing what we know about ODD pathogenesis and previously tried treatment strategies. In this context, we discuss current knowledge about calcium and pathological calcifications, including intracranial and ocular calcifications. We also explore some of the obstacles that must be addressed to develop a therapy centred on the concept of calcification, should calcification be identified as a pathogenic factor contributing to vision loss.

Posterior microphthalmos with retinal involvement related to MFRP gene: a report of 10 Brazilian patients

BACKGROUND

To describe the phenotype and genotype of 10 Brazilian patients with variants in MFRP, posterior microphthalmos and retinal findings.

METHODS

Complete ophthalmological evaluation was done at 4 different Brazilian centers. Genetic analysis was performed using commercial next generation sequencing panels for inherited retinal disorders.

RESULTS

Ages of the patients ranged from 10 to 65 years and visual acuities from 0,05 to no perception of light. All were hyperopes (+4,25 to + 17,50) with a short axial length (14,4 mm to 18 mm). Common posterior segment features, though not present in all, were optic disc drusen (5/10), foveoschisis (5/10) and retinal pigmentary changes (8/10). Isolated patients presented with macular atrophy, serous retinal detachment, and chorioretinal folds. The most common variant in MFRP found in our patients was a deletion in exon 5 (c.498delC; p.Asn267Thrfs *25), present in all except 2 patients. Other variants found were c.523C>T (p.Gln175*), c.298delG (p.Ala100Argfs *37), c.666del (p.Thr223Argfs *83) and the novel variant c.257C>A (p.Ala86Asp).

CONCLUSIONS

This is the first report of Brazilian patients with posterior microphthalmos and pathogenic variants in MFRP and the first describe of the variant p.Ala86Asp in literature. Our cases confirm the previously reported phenotype of high hyperopia, optic disc drusen, alterations in foveal architecture, retinal pigmentary changes with loss of photoreceptor function and visual field constriction. Report of such a rare condition is important to increase awareness to the phenotype of posterior microphthalmia with associated retinal conditions.

Case report: Unilateral papilledema in a dog with a large suprasellar mass and suspected intracranial hypertension: insights from funduscopy, optical coherence tomography, and magnetic resonance imaging

A spayed, 8-year-old female Poodle, weighing 5.7 kg, was presented with the chief complaint of vision impairment. Vision assessment, including pupillary light reflexes, menace response, dazzle reflex, and maze navigation in photopic and scotopic circumstances, revealed a negative response in both eyes except for positive direct pupillary light reflex in the right eye and positive consensual pupillary light reflex from the right eye to the left eye. Systemic evaluation, including neurologic status, blood profile, and thoracic radiographs, did not reveal any abnormalities. Complete ophthalmic examinations, ocular ultrasonography, and electroretinography did not identify a cause of blindness. Upon funduscopy, the left eye exhibited an increased optic disk diameter, blurred optic disk borders, and loss of the physiologic pit, as well as an increase in vascular tortuosity. In the right eye, there were multifocal depigmented areas in the non-tapetal fundus and several pigmented spots surrounded by a region of dull tapetal reflection in the tapetal fundus. The optical coherence tomography revealed severe anterior deformation of the optic nerve head and Bruch's membrane in the peripapillary region of the left eye. Magnetic resonance imaging revealed an irregular, broad-based suprasellar mass, with features suggestive of intracranial hypertension, including dorsal displacement of third ventricles, a rightward shift of the falx cerebri, trans-tentorial herniation, perilesional edema, flattening/protrusion of the posterior sclera, and lager optic nerve sheath diameter in left side than right side. This is the first comprehensive report that describes unilateral papilledema in a dog with a brain tumor, using advanced ophthalmic and neuro-imaging modalities.

Retro-mode imaging for the diagnosis of optic disc drusen: a case series

OBJECTIVE

We aimed to compare the detectability of optic disc drusen (ODD), using various non-invasive imaging techniques, including the novel retro-mode imaging (RMI), as well as to analyze the morphological characteristics of ODD on RMI.

METHODS

This study involved seven patients with bilateral ODD, totaling 14 eyes. Multimodal imaging techniques, including multicolor fundus photography (MC), near-infrared reflectance (NIR), green and blue light fundus autofluorescence (G-FAF and B-FAF, respectively), and RMI were used to examine the eyes. FAF was used as the primary method of identifying ODD, and each method's detection rate was compared by two observers. Quantitative measurements of ODD included the number of ODD visualized by the RMI technique, the perimeter (P) and area (A) of ODD were identified.

RESULTS

The average age of the patients included was 49.28 ± 23.16 years, with five of the seven being men. RMI was able to detect ODD in all cases, with a sensitivity of 100%, compared to MC (sensitivity 60.71%), NIR (sensitivity 60.71%), B-FAF (sensitivity 100%), G-FAF (sensitivity 100%). RMI was the only imaging technique capable of assessing ODD morphology and quantifying ODD.

CONCLUSIONS

RMI is a promising imaging modality for diagnosing superficial ODD, providing valuable information on the distribution, location, and size of ODD. We suggest the incorporation of RMI as a complementary tool for diagnosing and monitoring ODD in combination with other multimodal imaging methods.

Peripapillary hyperreflective ovoid mass-like structures: multimodal imaging and associated diseases

Growing evidence has demonstrated that peripapillary hyperreflective ovoid mass-like structures (PHOMS) are novel structures rather than a subtype of optic disc drusen. They correspond to the laterally bulging herniation of optic nerve fibers and are believed to be the marker of axoplasmic stasis. PHOMS present in a broad spectrum of diseases, including optic disc drusen, tilted disc syndrome, papilloedema, multiple sclerosis, non-arteritic anterior ischemic optic neuropathy, optic neuritis, Leber hereditary optic neuropathy, and so on. We focus on the multimodal imaging features, pathophysiological mechanisms of PHOMS, and their association with multiple diseases and healthy people in this review to deepen the ophthalmologists' understanding of PHOMS. Additionally, we provide some new directions for future research.

Optical coherence tomography angiography findings in optic disc drusen and idiopathic intracranial hypertension

PURPOSE

To evaluate the changes in peripapillary microvascularity in idiopathic intracranial hypertension (IIH) and optic disc drusen (ODD) patients, by comparing them with those in healthy individuals, via optical coherence tomography angiography (OCTA).

METHODS

Sixty-two eyes of 33 patients with ODD, 58 eyes of 30 patients with IIH, and 70 eyes of 70 healthy people were imaged for 6 × 6-mm optic disc scans on a spectral-domain OCTA. Vascular densities in superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC) of ODD, IIH, and healthy eyes were compared with a one-way analysis of variance. Post-hoc analysis was performed with the Gabriel test.

RESULTS

There was a significant decrease in peripapillary vessel density in SCP, DCP, and CC in patients with IIH compared to the control group (p < 0.05). In ODD patients, especially peripapillary vessel density in DCP was significantly reduced compared to the control group (p < 0.05). Peripapillary vessel density in DCP was significantly lower in the IIH group than ODD group (p < 0.05).

CONCLUSIONS

Peripapillary vascular density may be affected during the course of the disease in both IIH and ODD. Compared to healthy individuals, the decrease in vascular density in these patients and the consequent decrease in perfusion in the peripapillary region may guide the pathogenesis of the complications in the course of these two diseases. Although vascular density in DCP and CC differs significantly between IIH and ODD, case-controlled studies are needed to evaluate the role of OCTA in the differential diagnosis of IHH and ODD.

Prevalence of optic disc drusen: A systematic review, meta-analysis and forecasting study

Optic disc drusen (ODD) are calcium-containing deposits in the optic nerve head, capable of causing visual field defects and sudden visual loss. The underlying pathophysiology remains inadequately understood and treatment options are missing. In this paper, we systematically reviewed prevalence studies of ODD in non-selected populations to provide an overview of its prevalence, conducted meta-analyses to determine modality-specific prevalence estimates and performed a forecasting study to estimate current and future global population number of individuals with ODD. We searched 11 literature databases on 25 October 2022 for prevalence studies of ODD in non-selected populations. Eight eligible studies provided data from a total of 27 463 individuals. Prevalence estimates were stratified according to diagnostic modalities: ophthalmoscopy 0.37% (95% CI: 0.10-0.95%), fundus photography 0.12% (95% CI: 0.03-0.24%), spectral domain optical coherence tomography with enhanced depth imaging 2.21% (95% CI: 1.25-3.42%) and histopathology 1.82% (95% CI: 1.32-2.38%). Using histopathology-based summary prevalence estimate, we forecast 145 million individuals with ODD currently, a number expected to increase further due to world population growth. These numbers underscore the importance of including ODD in health education and highlight the necessity of continuing research in ODD.

Concomitant optic disk drusen and papilledema due to idiopathic intracranial hypertension in a pediatric cohort

BACKGROUND

Optic disk drusen (ODD) in pediatric patients typically presents with pseudopapilledema. Diagnosing concomitant papilledema due to idiopathic intracranial hypertension (IIH) in these patients can be challenging. The purpose of this study was to evaluate the incidence and clinical features of papilledema due to IIH among pediatric patients with a new diagnosis of ODD and to discuss the clinical and paraclinical findings that helped diagnose this group.

METHODS

The medical records of children <15 years of age with ODD confirmed by B-scan ultrasound at their first visit over a 4-year period (2019-2022) were reviewed retrospectively. Patients with concurrent IIH were identified, and the demographic and clinical characteristics were reviewed.

RESULTS

A total of 83 children with confirmed ODD at the initial presentation were included, of whom 4 (4.8%) were diagnosed with concomitant IIH. Patients ranged in age from 7 to 15 years; 3 of the 4 were female, and 3 had IIH-related symptoms at presentation (1 was asymptomatic). None of the 4 patients had papilledema greater than Frisen grade 2.

CONCLUSIONS

We recommend that clinicians review pertinent IIH symptoms and risk factors in children with ODD and follow the standard workup for IIH in suspicious cases. In asymptomatic patients with a new diagnosis of ODD, we recommend obtaining a follow-up optic nerve evaluation and optical coherence tomography scan to detect any significant interval change that might serve as a possible indicator of concomitant papilledema.

Idiopathic intracranial hypertension: a step change in understanding the disease mechanisms

The understanding of idiopathic intracranial hypertension (IIH) has evolved over the past few years. Previously, IIH was considered a disease exclusively affecting the neuro-ophthalmic axis, characterized by raised intracranial pressure, headache and papilloedema, and resulting in the risk of severe and permanent visual loss and life-changing disabling headaches. Recent advances have begun to redefine IIH as a probable metabolic disease involving a range of systemic manifestations. More than 95% of individuals affected by the disease are women of reproductive age with obesity. The incidence is rapidly rising and parallels the escalating worldwide obesity rates. Contemporary insights identify associations with insulin resistance, type 2 diabetes and a twofold increased risk of cardiovascular disease in excess of that driven by obesity alone. Adipose distribution in people with IIH, like that in other metabolic diseases, is preferentially centripetal and is associated with changes in intracranial pressure. Evidence now demonstrates adipose tissue dysfunction in people with IIH, involving transcriptional and metabolic priming for lipogenesis and weight gain. Hormonal perturbations are also observed, including a unique phenotype of androgen excess that promotes cerebrospinal fluid secretion. Knowledge of these additional disease features is driving research into novel therapeutic targets and altering the approach to multidisciplinary care.

Visual Field Defects in Patients With Optic Nerve Head Drusen

Background Optic nerve head drusen (ONHD) are acellular deposits in the optic nerve head, whose pathophysiology remains not fully understood. Most patients with ONHD have visual field (VF) defects. This study aims to describe the VF defects observed in patients with ONHD and to compare the anatomical and functional impairment between visible and buried ONHD. Methods Patients with ONHD were retrospectively studied. The retinal nerve fiber layer (RNFL) average thickness and the ganglion cell complex (GCC) average thickness were collected from optical coherence tomography data. Visual field index (VFI), mean deviation (MD), and pattern standard deviation (PSD) were collected from 30-2 standard automated perimetry. An abnormal VF test was defined as having a Glaucoma Hemifield Test outside normal limits and/or a PSD with a p-value<5%. Eyes with superficial or buried ONHD based on visibility by slit-lamp ophthalmoscopy were compared. Results Sixty-six eyes of 36 patients were included in the study. The mean age was 39.6 ± 2.5 years. Forty-nine eyes (81.7%) presented a VF defect: concentric VF constriction in 19 (38.8%), arcuate scotoma in 16 (32.7%), enlarged blind spot in 9 (18.4%), unspecific VF defect in 8 (16.3%), and nasal step in 3 (6.1%). Thirty-four eyes (51.5%) had superficial ONHD and 32 eyes (48.5%) had buried ONHD. Patients with superficial ONHD were significantly older (p<0.001) and presented a significantly lower VFI (p=0.010), lower MD (p=0.002), higher PSD (p<0.001), thinner GCC (p<0.001), and thinner RNFL (p<0.001) than patients with buried ONHD. VF defects were present in 90.6% of eyes with superficial ONHD and 71.4% of eyes with buried ONHD (p=0.113). The type of VF defects differed between groups (p=0.020). Conclusions Functional and structural impairment is more evident in eyes with superficial ONHD, maybe because the presence of calcification leads to greater axonal damage. Buried ONHD is more prevalent in younger patients, progressing to a superficial location and becoming calcified with age.

Artificial Intelligence-Based ChatGPT Responses for Patient Questions on Optic Disc Drusen

INTRODUCTION

Optic disc drusen (ODD) are acellular deposits in the optic nerve head, which are most often benign and asymptomatic. Patients may develop visual field defects and be at increased risk of ischemic co-morbidities. As ODD can be difficult to distinguish from papilledema, patients are at risk of unnecessary clinical workups. Patient information is a key aspect of ODD management. In this study, we explored the accuracy of ChatGPT responses for typical patient questions on ODD.

METHODS

Two content experts reached consensus on 20 typical patient questions. We retrieved five separate responses for each question from ChatGPT, totaling 100 responses. Each response was evaluated on a 5-point Likert-scale on accuracy by each content expert in an individual fashion.

RESULTS

The two experts were in fair/substantial agreement in the evaluation of responses (Cronbach's alpha: 0.64). Of the 100 responses, 17 were relevant and without any inaccuracies, 78 were relevant and with inaccuracies not being harmful, and five were relevant and with inaccuracies potentially harmful. The lowest accuracy scores were obtained for questions dealing with treatment and prognosis.

CONCLUSIONS

ChatGPT often provides relevant answers for patient questions on ODD, but inaccuracies become potentially harmful when questions deal with treatment and prognosis.

Understanding pseudopapilledema on spectral domain optical coherence tomography

Purpose

Optic nerve head drusen (ONHD), peripapillary hyperreflective ovoid mass-like structures (PHOMS), and horizontal hyperreflective lines (HHL) are commonly seen in eyes with pseudopapilledema on enhanced depth imaging (EDI) spectral domain optical coherence tomography (SDOCT). The objective of this study is to assess the frequency of ONHD, PHOMS, and HHL on spectral domain OCT in the eyes diagnosed to have pseudopapilledema.

Methods

A retrospective case-control study included patients diagnosed as pseudopapilledema and had EDI SD OCT imaging of the optic nerve head (n = 48 eyes) and controls (n = 20 eyes). OCT scans through the optic nerve head were studied to diagnose ONHD, HHL, and PHOMS. One proportion z test was used to find the difference in proportions.

Results

Forty eight eyes of 27 subjects were studied. ONHD as described by the optic disc drusen Studies consortium was noted in 19 eyes (39.48%), P value-0.032, PHOMS in 31 eyes (64.6%), P value 0.043, HL in 19 eyes (39.48%), P value 0.032, and none of the normals had ONHD, PHOMS, and HHL.

Conclusions

PHOMS are more frequently seen than ONHD and HHL in eyes with pseudopapilledema.

The Presence of Optic Disc Drusen in Eyes with Uveitis

PURPOSE

To evaluate the coexistence of optic disc drusen (ODD) in eyes with uveitis.

METHODS

In this retrospective, observational study, patients followed up in a uvea clinic with all types of uveitis were evaluated. ODD were confirmed by ocular ultrasonography, optic nerve head enhanced-depth imaging optical coherence tomography, fundus autofluorescence, and fundus photography.

RESULTS

ODD were detected in 17 of 545 (3.1%) uveitis patients. The mean age was 18.9 ± 10.4 years, and 76.5% were female. 45.5% were anterior, 42.4% were panuveitis, 6.1% were intermediate, and 6.1% were posterior uveitis. ODD were found bilaterally in all 17 patients; uveitis was unilateral in one patient. 58.8% were under the age of 18, and in this group, the rate of buried ODD was 78.9% (p = 0.039). In adults (seven patients), ODD were buried in 42.9%.

CONCLUSION

ODD can be detected in eyes with uveitis and may clinically mimic optic disc edema, lead to misdiagnosis and/or overtreatment.

Peripapillary Vessel Density in Relation to Optic Disc Drusen: A Multimodal Optical Coherence Tomography Study

BACKGROUND

Optic disc drusen (ODD) are acellular calcified deposits within the optic nerve head known to cause visual field defects. An emerging gold standard for the diagnosis of ODD is enhanced depth imaging optical coherence tomography (EDI-OCT). The presence of ODD affects the adjacent peripapillary vasculature, which can be visualized using OCT angiography (OCTA). This study investigates the association between peripapillary vessel density and anatomical ODD location and volume using a newly developed method of multimodal OCT.

METHODS

A case-control study with 16 patients diagnosed with ODD in the period 2008-2017 and 24 healthy controls. All patients and controls had EDI-OCT, OCTA, and demographic data collected. Using EDI-OCT and the medical imaging segmentation tool ITK-SNAP, 3-dimensional (3D) visualization of ODD in patients were created. ODD 3D visualization and corresponding OCTA scans were superimposed, making it possible to correlate ODD volume to the peripapillary vessel density in the corresponding modified Garway-Heath segments of the optic disc.

RESULTS

We found that mean peripapillary vessel density across all modified Garway-Heath segments were lower in ODD patients compared with controls with significant reduction of peripapillary vessel density in the superior segment ( P = 0.03) and globally ( P = 0.05). A significant inverse proportionality between ODD volume and peripapillary vessel density in the corresponding segment was seen ( P = 0.002).

CONCLUSIONS

We found a reduced peripapillary vessel density in regions with close anatomical proximity to ODD and inverse proportionality between ODD volume and peripapillary vessel density.

Morpho-Functional Assessment of Retinal Ganglion Cells and Visual Pathways in Patients with Optic Disc Drusen: Superficial Drusen Visible Height as a Marker of Impairment

The aim of this study was to assess the morpho-functional involvement of the retinal ganglion cells (RGCs) and of the visual pathways in patients with superficial (ODD-S) or deep (ODD-D) optic disc drusen. This study enrolled 17 patients with ODD (mean age of 59.10 ± 12.68 years) providing 19 eyes and 20 control subjects (mean age 58.62 ± 8.77 years) providing 20 eyes. We evaluated the following: best-corrected visual acuity, visual field mean deviation (MD), the amplitude (A) of Pattern Electroretinogram (PERG), the implicit time (IT) and A of Visual Evoked Potentials (VEPs), retinal nerve fiber layer thickness (RNFL-T) and ganglion cell thickness (GC-T). In ODD-S eyes, the drusen visible height was measured. ODD-D and ODD-S were detected in 26.3% and 73.7% of ODD eyes, respectively. Significantly (p < 0.01) reduced MD, PERG A, VEP amplitude, RNFL-T and GC-T values and significantly (p < 0.01) increased VEP IT values were found in the ODD Group as compared to the Control one. In the ODD Group, no significant correlation (p > 0.01) between PERG As and VEP ITs was found. In ODD-S, the visible height was significantly correlated (p < 0.01) with reduced MD, PERG As and RNFL-T and with increased PSD and VEP IT values. Our findings suggest that ODD might induce morpho-functional changes in RGCs and their fibers and an unrelated visual pathway dysfunction leading or not leading to visual field defects. The observed morpho-functional impairment should be ascribed to an alteration in retrograde (from the axons to the RGCs) and anterograde (from the RGCs up to the visual cortex) axoplasmic transport. In ODD-S eyes, a minimum visible height of 300 microns represented the threshold for the abnormalities, suggesting that "the higher the ODD, the worse the impairment".

A Comparison of Diagnostic Accuracy of Imaging Modalities to Detect Optic Disc Drusen: The Age of Enhanced Depth Imaging Optical Coherence Tomography

PURPOSE

To identify the most accurate diagnostic imaging modality to detect optic disc drusen (ODD) between B-scan ultrasonography (US), fundus photography, fundus autofluorescence (FAF), and enhanced depth imaging optical coherence tomography (EDI-OCT).

DESIGN

Comparative diagnostic analysis.

METHODS

Two hundred five eyes of 105 patients referred to 2 tertiary care neuro-ophthalmology clinics for suspected ODD were recruited: 108 eyes had ODD and 97 did not have ODD. All eyes received a full in-person ophthalmic exam with 3D view of the optic nerve and all 4 imaging modalities. Images were independently reviewed by 3 masked neuro-ophthalmologists to determine the presence or absence of ODD. Final interpretation was made through consensus. The reference standard was defined as the attending ophthalmologist's clinical judgement based on open chart review, with access to all image modalities and clinical information, including disease course. Main outcome measures were sensitivity, specificity, accuracy, and precision for each imaging modality. Examiner confidence was quantified as the proportion of eyes in which the reviewers were certain of their decision.

RESULTS

The EDI-OCT had the highest sensitivity and accuracy (95%, 97%) to detect ODD, compared with FAF (84%, 92%), US (74%, 86%), and fundus photography (38%, 66%), respectively. All image modalities had high specificity (> 97%) and precision (> 93%). The EDI-OCT also had highest examiner confidence (96%) compared with all others (88%).

CONCLUSIONS

Among all modalities, EDI-OCT was the imaging modality with the highest diagnostic utility for the detection of ODD and should be considered as the preferred initial diagnostic modality.

Optic nerve sheath diameter and axial length in patients with optic disc drusen: a cross-sectional study

AIM

Measuring the optic nerve sheath diameter (ONSD) and the anteroposterior axial length of the eye in patients with optic disc drusen (ODD).

METHODS

A total of 43 healthy volunteers and 41 patients with ODD were included in the study. The ONSD and axial length were measured in the posterior position using an ultrasound device (E-Z Scan AB5500 +) probe with a 10 MHz frequency. The ONSD was measured 3 mm behind the globe wall. Receiver operating characteristic (ROC) curve analysis was performed to determine patients with ODD using ONSD. Any p-value of < 0.05 was accepted to demonstrate significance.

RESULTS

The ONSD was significantly higher (5.2 mm and 4.8 mm, p = 0.006, respectively), and the axial length was shorter (21.82 ± 2.15 mm and 23.27 ± 1.96 mm, p = 0.002, respectively) in the ODD group. The spherical equivalent was more commonly seen as hypermetropic in the ODD group (1.00 [- 0.85 to 1.75]). In the ROC analysis to determine the ONSD value in ODD diagnosis, the area under the curve was 0.6754 (95% confidence interval 0.559-0.788, p = 0.006). ONSD cutoff of 5.70 mm had a sensitivity of 0.366 and a specificity of 0.907 to diagnose ODD.

CONCLUSION

In this study, the ONSD was significantly higher in the ODD group. The axial length was shorter in the ODD group. This study is the first in the literature to evaluate the ONSD in patients with optic disc drusen. Further studies are needed in this regard.

Discriminating Healthy Optic Discs and Visible Optic Disc Drusen on Fundus Autofluorescence and Color Fundus Photography Using Deep Learning-A Pilot Study

The aim of this study was to use deep learning based on a deep convolutional neural network (DCNN) for automated image classification of healthy optic discs (OD) and visible optic disc drusen (ODD) on fundus autofluorescence (FAF) and color fundus photography (CFP). In this study, a total of 400 FAF and CFP images of patients with ODD and healthy controls were used. A pre-trained multi-layer Deep Convolutional Neural Network (DCNN) was trained and validated independently on FAF and CFP images. Training and validation accuracy and cross-entropy were recorded. Both generated DCNN classifiers were tested with 40 FAF and CFP images (20 ODD and 20 controls). After the repetition of 1000 training cycles, the training accuracy was 100%, the validation accuracy was 92% (CFP) and 96% (FAF), respectively. The cross-entropy was 0.04 (CFP) and 0.15 (FAF). The sensitivity, specificity, and accuracy of the DCNN for classification of FAF images was 100%. For the DCNN used to identify ODD on color fundus photographs, sensitivity was 85%, specificity 100%, and accuracy 92.5%. Differentiation between healthy controls and ODD on CFP and FAF images was possible with high specificity and sensitivity using a deep learning approach.

The visual morbidity of optic nerve head drusen: a longitudinal review

BACKGROUND

The ophthalmologic complications of optic nerve head drusen (ONHD) in adults have been documented, whereas data on the degree of visual morbidity from OHND in children are limited.

METHODS

The medical records of all patients diagnosed with ONHD at a single, tertiary care ophthalmology department from January 1, 2010, until July 1, 2018, were reviewed retrospectively. Patients were identified using ICD-9 and ICD-10 codes. Inclusion criteria were age ≤18 years of age and formal documentation of ONHD by ancillary testing.

RESULTS

A total of 213 patients (386 eyes with ONHD) met inclusion criteria. Mean age at diagnosis was 10.13 ± 4.09 years, and mean follow-up was 2.76 ± 2.91 years. Formal visual fields were available for 208 eyes. Repeatable visual field defects were noted in 24 eyes (11.5%). The most common defect was a nasal step, which occurred in 11 eyes (45.8%). Fifteen eyes had visual field defects at presentation, and 9 eyes developed field loss within 1.39 ± 0.55 years of diagnosis. There was no correlation found between intraocular pressure and degree of visual field loss. Choroidal neovascular membranes were clinically apparent in 5 eyes and treatment was required in 3 eyes. Nonarteritic ischemic optic neuropathy developed in 2 eyes.

CONCLUSIONS

Visual morbidity associated with ONHD in children is common and may develop in a short period of time after initial diagnosis. There was no correlation found with intraocular pressure.

Eye and headache: Not always an inseparable association

Not available for the section "Images in Emergency".

Optic Disc Drusen in Patients With Ocular Hypertension: A Case Series and Review of the Literature

BACKGROUND

The identification of glaucomatous optic neuropathy in the setting of optic disc drusen (ODD) is a challenge, and the decision of whether to offer treatment in the form of intraocular pressure (IOP) reduction is controversial. Here, we present a series of patients with coexisting ocular hypertension and ODD to evaluate clinical features, treatment options, and progression of optic neuropathy. In addition, a review of the literature on ODD with elevated IOP is provided.

METHODS

Six patients with ODD and a history of ocular hypertension are presented. Components of the examination and imaging modalities used to establish the diagnosis of ODD were recorded and a description of ocular hypertension history, glaucoma testing, and the potential treatment of IOP were also provided.

RESULTS

In this series, 4 of 6 patients with concurrent ocular hypertension and ODD showed progression of optic neuropathy as assessed by visual field or retinal nerve fiber layer thickness. Of the 2 patients who did not show evidence of progression, 1 was treated with IOP-lowering medications and 1 was observed off treatment. Of the 4 patients who showed evidence of progression, all 4 were initially treated with IOP-lowering medications and 2 ultimately went on to have trabeculectomy surgery. In the patients with progressive optic neuropathy, lowering the IOP seemed to halt the progression suggesting there was a pressure-sensitive component.

CONCLUSIONS

Distinguishing changes to the optic nerve, particularly the structural changes at the lamina cribrosa of true glaucomatous optic neuropathy in the setting of ODD, is a challenge. Careful consideration of risk factors including age, presenting features, progression indicators, and management goals is to be accounted for in the decision to offer treatment. We see the presence ODD in the patients with ocular hypertension as an additional risk for progressive changes to the nerve fiber layer and visual field that needs to be considered when determining whether to initiate therapy. Our data suggest that treatment of IOP in the patients with ocular hypertension with ODD and evidence of progression reduces the risk of further progression. Further work is needed to determine whether progression of optic neuropathy in the setting of coexisting ODD and ocular hypertension is related mechanistically to predominantly an ODD-type process, a glaucomatous process, or a combination thereof.

Optic Disc Drusen (ODD), an Often Misdiagnosed Disease: A Case Report

Optic disc drusen (ODD) are abnormal collections of protein and calcium that accumulate within the optic nerve. We report a case of a 17-year-old girl who presented to the Department of Ophthalmology at the Cheikh Khalifa International University Hospital, Casablanca, Morocco, with a decline in visual acuity, visual field deficiency, and color vision abnormalities. The patient was misdiagnosed and mistreated for optic neuritis given the presence of bilateral Stage III papilledema solely. After many months of diagnostic wandering, a fundus examination revealed a white atrophic papilla with calcified deposits grouped in a crown around the papillary excavation, suggesting papillary drusen. When the deposits are visible on ophthalmoscopy and manifest as an elevation and a blurring of the optic disc's margins, their diagnosis remains straightforward. However, their identification might be problematic when they are firmly lodged in the optic disc or with the presence of papilledema, leading to confusion with other differential diagnoses, particularly if the condition affects both eyes. The purpose of this case report is to increase neurologists' and ophthalmologists' knowledge of the incidence of drusen in order to prevent excessive biological and imaging investigation in addition to harmful effects from needless drugs.

Optic disc drusen in patients diagnosed with normal tension glaucoma

PURPOSE

To investigate the prevalence of optic disc drusen (ODD) and optic nerve head (ONH) morphology in patients diagnosed with normal tension glaucoma (NTG).

METHODS

In this prospective cross-sectional study, we included patients diagnosed with NTG from two glaucoma units. In both eyes, dense enhanced depth imaging optical coherence tomography volume scans of the ONH by means of standardized scanning guidelines were performed to examine for presence of ODD, and radial ONH scans were used for investigating parameters such as scleral canal diameter, cup/disc ratio and cup depth.

RESULTS

We found ODD in 7 (3.6%) of 195 eyes, in 6 (6.1%) out of 98 patients diagnosed with NTG. The ODD were not ophthalmoscopically visible in five out of six patients. Eyes with ODD had lower cup/disc ratio, 0.44 ± 0.4 (p = 0.040), and less-prominent cup depth, 236.6 ± 204.4 μm (p = 0.041) compared to eyes without ODD, 0.81 ± 0.2 and 437.8 ± 139.1 μm, respectively. We found no significant difference in scleral canal diameter between the eyes without (1602.8 ± 193 μm) and those with ODD (1492 ± 123.4 μm, p = 0.057).

CONCLUSION

The prevalence of ODD in patients diagnosed with NTG is substantially higher than in the background population. A low cup/disc ratio correlates with ODD presence. Therefore, due to the challenges associated with NTG diagnosis, we recommend examining the deep layers of the ONH in NTG patients with a cup/disc ratio lower than 0.5 to avoid misdiagnosing ODD as NTG.

An overview of peripapillary hyperreflective ovoid mass-like structures

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the ophthalmic findings associated with peripapillary hyperreflective ovoid mass-like structures (PHOMS) in both adult and pediatric patients.

RECENT FINDINGS

PHOMS have recently been identified in a number of different ophthalmic disease entities ranging from nonpathologic to pathologic, including but not limited to anatomic abnormalities (tilting in myopia), optic nerve head drusen, optic disc edema from inflammation (optic neuritis, white dot syndromes), vascular insults (ischemic optic neuropathy, retinal vascular occlusion), and papilledema. The mechanism underlying the formation of PHOMS has not been fully elucidated although it has been hypothesized that PHOMS occur secondary to axoplasmic stasis from crowding at the optic nerve head.

SUMMARY

Although the clinical significance of the presence of PHOMS remains unclear, PHOMS are associated with several disease processes. Understanding the mechanism behind their formation and their impact on optic nerve head structure and visual function may be relevant in patients with optic nerve head pathology. The presence of PHOMS may also correlate with disease severity and duration. Future studies to evaluate whether the formation of PHOMS may be useful as an early indicator of disease or a prognostic tool are warranted.

Comparison of Spectral-Domain OCT versus Swept-Source OCT for the Detection of Deep Optic Disc Drusen

Deep optic disc drusen (ODD) are located below Bruch’s membrane opening (BMO) and may go undetected due to the challenges in imaging them. The purpose of this study is a head-to-head comparison of currently widely used imaging technologies: swept-source optical coherence tomography (SS-OCT; DRI OCT-1 Triton, Topcon) and enhanced depth imaging spectral-domain optical coherence tomography (EDI SD-OCT; Spectralis OCT, Heidelberg Engineering) for the detection of deep ODD and associated imaging features. The eyes included in this study had undergone high-resolution imaging via both EDI SD-OCT and SS-OCT volume scans, which showed at least one deep ODD or a hyperreflective line (HL). Grading was performed by three graders in a masked fashion. The study findings are based on 46 B-scan stacks of 23 eyes including a total of 7981 scans. For scan images with ODD located above or below the level of BMO, no significant difference was found between the two modalities compared in this study. However, for HLs and other features, EDI SD-OCT scan images had better visualization and less artifacts. Although SS-OCT offers deep tissue visualization, it did not appear to offer any advantage in ODD detection over a dense volume scan via EDI SD-OCT with B-scan averaging.

[Optical coherence tomography in the differential diagnostics of important neuro-ophthalmological disease patterns]

There are many disease patterns that are treated jointly by neurologists and ophthalmologists, for which optical coherence tomography (OCT) is of important differential diagnostic significance. In this context neurologists are mainly confronted by two patient collectives: patients with an acute ischemic event, who present with an acute but painless monocular visual deterioration (for central retinal artery occlusion) or with a monocular visual field defect (for arterial branch occlusion or anterior ischemic optic neuropathy). The second collective is patients without ophthalmological symptoms but with conspicuous optic nerve findings (papilledema or optic disc drusen). In this overview article both patient collectives are considered separately. In addition, the most important OCT findings for optic neuritis are presented. Before the disease patterns are described in detail, the normal OCT findings and the diagnostic possibilities of OCT are explained.

Macular and Optic Disc Parameters in Children with Amblyopic and Nonamblyopic Eyes under Optical Coherence Tomography Fundus Images

The aim of this study was to investigate the characteristics of macular and optic disc parameters in children with amblyopic and nonamblyopic eyes, using fundus images under optical coherence tomography (OCT). 36 patients with anisometropic amblyopia were selected in the experimental group, and another 36 healthy volunteers were selected in the control group, OCT examinations were performed in all groups, and the mean diopter, mean corrected visual acuity (CVA), mean axial length, mean optic disc retinal nerve fiber layer (RNFL) thickness, and mean macular fovea thickness were recorded in the two groups. The results found that the average diopter of the patients in the control group and the experimental group was +2.30 ± 2.54 D and +5.51 ± 1.76 D, respectively. The average CVA was 0.86 ± 0.07 and 0.22 ± 0.16, respectively; the average eye axial length was 22.41 ± 1.20 mm and 21.11 ± 0.78 mm, respectively. As P < 0.05, the differences were statistically significant in the three indicators between the two groups. There was no significant difference between the two groups in the average thickness of the RNFL of the optic disc and the average thickness of the central fovea of macula (P > 0.05). There was some correlation among CVA, diopter, eye axial length, RNFL thickness, and average thickness of macular fovea, but the correlation was not significant. It was suggested that there were certain differences in the macular and optic disc parameters between amblyopic and nonamblyopic children, but the difference is little. Thereout, a certain objective basis was provided for the early detection and treatment of amblyopia.

[Optical coherence tomography in the differential diagnostics of important neuro-ophthalmological disease patterns]

There are many disease patterns that are treated jointly by neurologists and ophthalmologists, for which optical coherence tomography (OCT) is of important differential diagnostic significance. In this context neurologists are mainly confronted by two patient collectives: patients with an acute ischemic event, who present with an acute but painless monocular visual deterioration (for central retinal artery occlusion) or with a monocular visual field defect (for arterial branch occlusion or anterior ischemic optic neuropathy). The second collective is patients without ophthalmological symptoms but with conspicuous optic nerve findings (papilledema or optic disc drusen). In this overview article both patient collectives are considered separately. In addition, the most important OCT findings for optic neuritis are presented. Before the disease patterns are described in detail, the normal OCT findings and the diagnostic possibilities of OCT are explained.

Diabetic papillopathy in patients with optic disc drusen: Description of two different phenotypes

PURPOSE

To describe two cases of severe acute bilateral optic disc edema that occurred in patients with diabetes mellitus shortly after the initiation of intensified antihyperglycemic therapy.

METHODS

Retrospective observational case report.

CASE DESCRIPTION

Two patients with type 1 diabetes presented for routine retinopathy screening with asymptomatic optic disc edema. One case was bilateral, the other unilateral. Neither patient had visual complaints. Both patients' glycemia history was characterized by a recent bout of poor regulation and both had optic disc edema consistent with diabetic papillopathy in combination with prominent Optic disc drusen (ODD). The swelling that appeared to constitute the edematous diabetes-related component of the disease resolved within 10-12 weeks during which diabetes therapy was optimized. Visual field deficits were seen early on in both patients and had resolved to some extent in one patient after 9 months but persisted in the one affected eye in the other patient up to at least 30 months.

CONCLUSION

Two cases of ODD-associated diabetic papillopathy were observed: One with classic, bilateral disc edema and minor visual field defects, the other with unilateral disc edema, severe visual field defects and a phenotype that resembled non-arteritic anterior ischemic optic neuropathy. The cases suggest that ODD may increase the risk of diabetic papillopathy, a condition that is associated with rapid glycemia reduction and crowded optic discs, which may combine to produce nerve fiber swelling and hypoperfusion with venous congestion in a compartment with limited room for expansion.

Detection of superficial and buried optic disc drusen with swept-source optical coherence tomography

Background

To detect the superficial and buried optic disc drusen (ODD) with swept-source optical coherence tomography (SS-OCT).

Methods

Retrospective cross-sectional study. Twenty patients (age 18–74 years) diagnosed with ODD via B-scan ultrasonography were analysed. All patients underwent color fundus photography (CFP), B-scan ultrasonography, fundus autofluorescence (FAF), and SS-OCT. We defined each hyporeflective signal mass of SS-OCT as an ODD, recorded its location and relationship with Bruch’s membrane opening (BMO), and other ophthalmic imaging characteristics.

Results

Twenty (33 eyes) patients had 54 ODDs in all, except one eye did not show abnormal optic disc findings on SS-OCT. We classified ODD into three categories: ODD above BMO, ODD across BMO, and ODD below BMO. The ODDs across BMO were the largest, followed by ODDs below BMO, and those above BMO. The location of the ODDs: One (1.9%) was in the border tissue of Elschnig, 6 (11.1%) might span across the lamina cribrosa, 16 (29.6%) were above BMO located in the neuroepithelial layer, 9 (16.7%) spanned across BMO located near the center of the optic disc, 18 (33.3%) were below BMO located near the center of the optic disc, 4 (7.4%) were below BMO located within the optic disc rim. When the anterior margin was ≥ 100 μm from the BMO, clear autofluorescence could be seen.

Conclusion

Multimodal imaging provided a deeper understanding of ODD. SS-OCT illustrated more details about the relationship between the posterior surface of ODD, BMO and the lamina cribrosa.

Transorbital sonography: A non-invasive bedside screening tool for detection of pseudotumor cerebri syndrome

BACKGROUND

Our objective was to assess optic nerve sheath diameter (a marker of elevated intracranial pressure) and optic disc elevation (a marker of papilledema) in pseudotumor cerebri syndrome using transorbital sonography.

METHODS

The study was a prospective case-control study. We included patients with new-onset pseudotumor cerebri syndrome and matched healthy controls. All had fundoscopy, lumbar puncture with opening pressure and transorbital sonography. Sonography was assessed by a blinded observer.

RESULTS

We evaluated 45 patients and included 23 cases. We recruited 35 controls. Optic nerve sheath diameter was larger in pseudotumor cerebri syndrome compared to controls (6.3 ± 0.9 mm versus 5.0 ± 0.5 mm, p < 0.001) and so was optic disc elevation (0.9 ± 0.4 mm versus 0.4 ± 0.1 mm, p < 0.001). The optimal cut-off point for optic nerve sheath diameter was 6 mm with a sensitivity of 74% for prediction of pseudotumor cerebri syndrome and 68% for prediction of elevated opening pressure. Specificity was 94%. The optimal cut-off point for optic disc elevation was 0.6 mm. Sensitivity was 100% and specificity 83% for prediction of pseudotumor cerebri syndrome.

CONCLUSION

Optic disc elevation and optic nerve sheath diameter are increased in new-onset pseudotumor cerebri syndrome. Optic disc elevation achieved high specificity and excellent sensitivity for diagnosis of pseudotumor cerebri syndrome. Transorbital sonography (TOS) is a potential, non-invasive screening tool for pseudotumor cerebri syndrome in headache clinics.

The Effects of Visual Field Loss from Optic Disc Drusen on Performance in a Driving Simulator

The purpose of this study was to compare the driving simulator performance of participants with visual field loss (VFL) from optic disc drusen (ODD) with a normally sighted control group and a group of individuals with glaucoma. Data on performance and safety from a traffic simulator test for five participants with VFL from ODD were retrospectively compared with data from 49 male individuals without visual deficits in a cross-sectional study. VFL of the ODD group was also compared with a group of 20 male glaucoma participants who had failed the same simulator test. Four individuals with ODD regained their driving licences after a successful simulator test and were then followed in a national accident database. All participants with ODD passed the test. No significant differences in safety or performance measures were detected between the normally sighted participants and the ODD group despite severe concentric visual field constrictions. Compared with failed glaucoma male participants, the ODD group had even lower mean sensitivity in the peripheral and peripheral inferior field of vision. None of the four participants with a regained licence were involved in a motor vehicle accident during a 3-year follow-up period after the simulator test. Despite having severe VFL, participants with ODD had no worse performance or safety than controls. As even individuals with severe VFL might drive safely, there is a need for individual practical assessments on licencing issues.

Volumetric Measurement of Peripapillary Hyperreflective Ovoid Masslike Structures in Patients with Optic Disc Drusen

Purpose

To develop a method to determine the volume of peripapillary hyperreflective ovoid masslike structures (PHOMS) and to examine the correlation between PHOMS and anatomic optic nerve head characteristics in a large cohort of patients with optic disc drusen (ODD).

Design

Retrospective, observational study of patients with ODD.

Participants

Patients with ODD seen in a 3-year period.

Methods

We determined the prevalence of PHOMS. We then developed a method to calculate the volume of PHOMS and measured this in all patients where radial scans on OCT were available. We analyzed the correlation between PHOMS volume and patient age, size of Bruch's membrane opening (BMO), ODD visibility, and anatomic location of ODD in the optic nerve.

Main Outcome Measures

Prevalence and characteristics of PHOMS in patients with ODD.

Results

In 247 (77%) eyes with ODD, PHOMS were found. Among these, 80% were in the first decade of life, 87% were in the second decade, 89% were in the third decade, 85% were in the fourth decade, 74% were in the fifth decade, 73% were in the sixth decade, 58% were in the seventh decade, 40% were in the eighth decade, and 0% were in the ninth decade. The ophthalmoscopic visibility of ODD increased with age. The volume of PHOMS decreased with age, but with no correlation to the size of BMO. The median volume of PHOMS was 0.27 mm3 (interquartile range [IQR], 0.13-0.49 mm3). Predominantly, PHOMS were observed in the nasal peripapillary area (87.5% nasal, 78.5% superior, 67% inferior, and 63.5% temporal).

Conclusions

In patients with ODD, PHOMS are seen frequently, with the highest prevalence in younger individuals. The volume of PHOMS decreases with age, and PHOMS are seen more frequently in patients with superficial ODD.

Enhanced depth imaging optical coherence tomography of the optic nerve head improves correct diagnosis in glaucoma suspects without glaucomatous optic disc morphology

An 83-year-old woman with a long history of glaucoma and optic disc drusen (ODD) was referred for neuro-ophthalmological second opinion. The patient had been treated for decades with bilateral intraocular pressure (IOP)-lowering eye drops, laser trabeculoplasty and trabeculectomy and had severe, bilateral loss of visual fields and retinal nerve fibre layer (RNFL) thinning on optical coherence tomography (OCT) despite IOP that never exceeded 24 mm Hg. On ophthalmoscopy, only a single ODD was visible in the left eye and no optic disc cupping was apparent in either eye. Enhanced depth imaging OCT (EDI-OCT) of the optic nerve head revealed bilateral multiple, large, deep ODD, which in itself could easily explain the visual field loss and RNFL thinning of this patient. Optic nerve head examination using EDI-OCT is highly recommended for patients with a history of glaucoma but without optic nerve head cupping to avoid a potential misdiagnosis with consequent unnecessary treatment.

Papilledema: A Review of the Pathophysiology, Imaging Findings, and Mimics

Increased intracranial pressure is the most common cause of papilledema. Multiple etiologies such as cerebral edema, hydrocephalus, space occupying lesions, infection, and idiopathic intracranial hypertension among others should be considered. Imaging plays a critical role in the detection of pathologies that can cause papilledema. MRI with contrast and CE-MRV, in particular, are key for the diagnosis of idiopathic intracranial hypertension. This review will focus in common and infrequent causes of papilledema, the role of imaging in patients with papilledema as well as its potential mimickers.

Enhanced Depth Imaging Optical Coherence Tomography Technology Reveals a Significant Association Between Optic Nerve Drusen Anterior Displacement and Retinal Nerve Fiber Layer Thinning Over Time

BACKGROUND

Optic disc drusen (ODD) are a dynamic phenomenon, and their appearance, size, and relative location may change. The purpose of this study is to evaluate and quantify the longitudinal changes of buried ODD with enhanced depth imaging (EDI) optical coherence tomography (OCT) over time.

METHODS

ODD were analyzed with Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany) and EDI technology. The peripapillary retinal nerve fiber layer (RNFL) thickness was also measured. The size and depth of ODD were compared between the baseline and study visit (at least 2 years of follow-up), and the changes were correlated with mean RNFL thickness. The repeatability, coefficient of variation, and cutoff values for size and depth on EDI-OCT were calculated.

RESULTS

Of 21 previously identified patients with ODD, only 12 patients (21 eyes) met the most recent diagnostic criteria according to the ODD Studies Consortium recommendations for using OCT-EDI technology. The 21 eyes were reanalyzed after a mean period of 44.7 ± 13.2 months (range: 24-71 months). Overall, 132 ODD were evaluated with a mean of 6.1 ± 2.5 ODD per eye and 1.9 ± 1.1 ODD per scan. Overall, we found a significant forward movement of the drusen between visits (P = 0.01). Most drusen (67.4%) moved anteriorly, and in approximately one-third (35.6%), this displacement exceeded the cutoff value (64.28 µm). Furthermore, we found a significant correlation between ODD shallowing and RNFL thinning during the follow-up (P ≤ 0.03; R ≥ 0.370). We did not find any significant changes in size measurements (P = 0.10) over time.

CONCLUSIONS

In approximately one-third of buried ODD, a significant anterior movement occurred over 2 years of follow-up, and this movement was associated with significant RNFL thinning. By contrast, no significant change was detected in the size of the buried ODD.

Evaluation of the signs and symptoms of pseudotumor cerebri syndrome in pediatric population

PURPOSE

Pseudotumor cerebri syndrome (PTC) is characterized by increased intracranial pressure without a space-occupying lesion and a normal cerebrospinal fluid (CSF) composition without evidence of CSF infection. In this study, we aimed to compare the symptoms, signs, and clinical characteristics of patients presenting with a preliminary diagnosis of pseudotumor cerebri syndrome (PTC) who were diagnosed and not diagnosed with PTC.

METHOD

We conducted a retrospective study of patients who were referred to our clinic with signs and symptoms of PTC. We compared the patients' symptoms, signs, and clinical characteristics who were diagnosed with PTC with those who were not diagnosed with PTC using modified Dandy criteria.

RESULTS

Ninety-four patients with the pre-diagnosis of PTC were included in the study. LP procedure was done in all patients. After LP, 75.3% of the patients were diagnosed with PTC, but 24.7% did not meet the criteria for PTC. A statistically significant relationship was found between the increase in headache complaints when leaning forward, headache that keeps the child from playing, and the CSF pressure level (p = 0.014, p = 0.019; p < 0.05). There was no statistically significant correlation between papilledema and CSF pressure level (p > 0.05). A statistically significant relationship was found between papilledema grade and CSF pressure level (p = 0.038; p < 0.05), and the rate of high CSF pressure in the groups with Grades 2-3 and Grade 4 papilledema was higher than that in the group with Grade 1 papilledema. Cranial nerve 6 palsy (CN6) (p = 0.048) and flattening of the posterior aspect of the globe (FPS) are found independent risk factors (p = 0.004 p < 0.05).

CONCLUSIONS

PTC signs and symptoms show variability among pediatric population.

Oxidative Stress in Optic Neuropathies

Increasing evidence indicates that changes in the redox system may contribute to the pathogenesis of multiple optic neuropathies. Optic neuropathies are characterized by the neurodegeneration of the inner-most retinal neurons, the retinal ganglion cells (RGCs), and their axons, which form the optic nerve. Often, optic neuropathies are asymptomatic until advanced stages, when visual impairment or blindness is unavoidable despite existing treatments. In this review, we describe systemic and, whenever possible, ocular redox dysregulations observed in patients with glaucoma, ischemic optic neuropathy, optic neuritis, hereditary optic neuropathies (i.e., Leber's hereditary optic neuropathy and autosomal dominant optic atrophy), nutritional and toxic optic neuropathies, and optic disc drusen. We discuss aspects related to anti/oxidative stress biomarkers that need further investigation and features related to study design that should be optimized to generate more valuable and comparable results. Understanding the role of oxidative stress in optic neuropathies can serve to develop therapeutic strategies directed at the redox system to arrest the neurodegenerative processes in the retina and RGCs and ultimately prevent vision loss.

Updates on ophthalmic imaging features of optic disc drusen, papilledema, and optic disc edema

Purpose of review

Optic nerve head elevation can be associated with vision loss. This review provides an update regarding key features of optic disc drusen (ODD) compared with papilledema from increased intracranial pressure and optic disc edema from other causes.

Recent findings

Clinical history and funduscopic examination are not sufficient to correctly diagnose different causes of optic nerve head elevation. Multimodal ophthalmic imaging is noninvasive and should be used as first-line diagnostic testing to distinguish optic disc edema or papilledema from pseudoedema. Advanced ophthalmic imaging, including enhanced depth imaging optical coherence tomography (EDI-OCT) and autofluorescence imaging, can visualize ODD at high resolution and determine whether there is optic disc edema. OCT angiography does not require contrast and can rapidly visualize papillary, peripapillary, and macular microvasculature and identify important vascular biomarker of ischemia and, potentially, visual prognosis.

Summary

Multimodal ophthalmic imaging can help in the diagnosis of ODD and optic disc edema and identify patients at high risk of vision loss and neurological issues in order to ensure appropriate diagnosis and treatment.

Optic disc drusen mimicking Idiopathic Intracranial Hypertension (IIH): rely on ultrasound

Optic nerve ultrasound is an established routine supplementary diagnostic tool for idiopathic intracranial pressure but it can also be helpful in avoiding misdiagnoses. We describe a case of an obese 15- year-old girl with persistent headaches, fundoscopic findings suggesting papilledema, normal brain imaging who underwent two lumbar punctures with unremarkable cerebrospinal fluid findings before ultrasound revealed optic disc drusen as the cause of the optic disc elevation.

Topographic Quadrant Analysis of Peripapillary Superficial Microvasculature in Optic Disc Drusen

Background: Limited information is known about the topographic effect of optic disc drusen (ODD) on peripapillary retinal nerve fibers and microvasculature. Objective: This study aims to understand the structural and functional impact of ODD in different quadrants of the optic disc. Methods: We performed a retrospective case-control study of 22 ODD patients (34 eyes) and 26 controls (33 eyes) to compare optical coherence tomography (OCT) retinal nerve fiber layer (RNFL), OCT angiography (OCTA), and corresponding static perimetry mean deviation (MD) calculated using the modified Garway-Heath map in different quadrants of the optic disc. OCTA was analyzed using custom MATLAB script to measure six parameters in a peripapillary annulus with large vessel removal: vessel area density (VAD), vessel skeleton density (VSD), vessel perimeter index (VPI), vessel complexity index (VCI), flux, and vessel diameter index (VDI). Results: Quadrant analysis revealed that OCTA VAD and VCI were significantly decreased in superior, nasal, and inferior but not temporal quadrant. RNFL, VSD, and VPI were significantly impacted only in the superior and nasal quadrants. Corresponding visual field MDs in all ODD eyes were not different in the four quadrants, although eyes with MD equal or worse than -5 dB (32%) had worst visual field corresponding to the superior quadrant of the optic disc (inferior arcuate visual field). Structure-structure comparison of OCT and OCTA showed high correlation of RNFL with multiple OCTA measurements in the superior, nasal, and inferior quadrants but not temporal quadrant. Structure-function analysis revealed significant correlation of VAD and VCI and visual field MD in every quadrant, but RNFL was only significantly correlated in the superior and inferior quadrants. Conclusions: Peripapillary VAD and VCI are decreased in more quadrants than RNFL, supporting the clinical utility of performing OCTA in addition to OCT. Consistent with the most common locations of ODD, five OCT/OCTA measurements (VAD, VCI, RNFL, VSD, VPI) are decreased in the superior and nasal quadrants. OCT/OCTA measurements were significantly impacted in contrast to the relatively mild effect on corresponding visual field MD, consistent with the idea that a decrease in objective structural and vascular measurements occurs without parallel change in subjective visual function in ODD.

Multimodal Imaging Features of Optic Disc Drusen

PURPOSE

To identify key en face multimodal imaging features of optic disc drusen (ODD).

DESIGN

Retrospective cross-sectional study.

METHODS

Setting: a single academic center. Patient orStudyPopulation: 786 patients (10-82 years of age) with diagnostic codes for optic disc drusen (ODD) in clinical notes extracted using natural language processing. Intervention orObservationProcedures: color fundus imaging, green-light and blue-light fundus autofluorescence (FAF), near-infrared reflectance (NIR), and enhanced-depth imaging optical coherence tomography (EDI-OCT). MainOutcomeMeasurements: Ophthalmic imaging characteristics and sensitivity of en face imaging compared with EDI-OCT.

RESULTS

A total of 38 patients (61 eyes) had high-quality EDI-OCT scans and en face multimodal imaging. Green-light FAF imaging had the highest diagnostic sensitivity (96.8%) for ODD and showed homogeneous hyperautofluorescence, whereas blue-light FAF imaging had heterogeneous brightness, which helped differentiate superficial from deep ODD. Blue-light FAF (93.5%) and NIR (91.8%) imaging were also sensitive tests and revealed papillary and peripapillary features that were not well seen on green-light FAF, including the size and depth of ODD, morphology of the optic disc, and common ODD-associated structures such as horizontal hyper-reflective lines and peripapillary hyper-reflective ovoid mass-like structures (PHOMS). Color fundus imaging had the lowest sensitivity (82%). There was good inter-rater reliability for all en face imaging modalities (P < .0001 for all).

CONCLUSIONS

In en face imaging, green-light FAF had the highest sensitivity for the diagnosis of ODD, whereas blue-light FAF and NIR images provided more information regarding the severity, location, depth, and size of ODD. In eyes that are negative on green-light FAF, EDI-OCT should be performed and provides the highest-resolution characterization of the entire optic disc to assess or rule out ODD.

Kinetic and static perimetry after 16 years and additional OCT-A analysis in eyes with long-lasting optic disc drusen

The aim of the study is to evaluate the progression of visual field (VF) defects over 16 years of observation and to assess abnormalities in vessels and retinal nerve fibre layer (RNFL) thickness in patients with optic disc drusen (ODD). Both static automated perimetry (SAP) and semi-automated kinetic perimetry (SKP) were performed in 16 eyes of 8 patients (mean age 54 years) with ODD among 26 eyes of 13 patients examined 16 years before. The area of I2e, I4e, III4e, and V4e isopters was measured in deg2. The MD and PSD parameters were estimated using SAP. Optical coherence tomography angiography (OCT-A) was additionally performed in 16 ODD eyes and 16 eyes of 8 healthy subjects to estimate the RNFL thickness and vessel density of the optic nerve disc and the macula. The differences in all isopter areas of SKP and SAP parameters after 16 years were not significant. The analysis of OCT-A showed a significant reduction of the vessel density and RNFL of the peripapillary area in each segment in patients with ODD, compared with the control group. The highest reduction of RNFL was observed in the superior segment of the optic disc area (92.56μm vs 126.63μm) also the macular thickness was decreased in ODD patients, compared with the control group. In the macula, there was a significant vascular defect in the whole superficial layer and in the parafoveal deep layer. A strong significant correlation of the parafoveal deep plexus with MD and PSD parameters was detected. In conclusion, VF loss due to ODD after 16 years of the follow-up was not significant both in SKP and SAP. ODD caused a reduced vessel density and RNFL, as well as macular thickness in OCT-A. SAP parameters were influenced by parafoveal deep plexus.

Peripapillary vessel density in pediatric cases with buried optic disk drusen

BACKGROUND

To evaluate the retinal nerve fiber layer (RNFL) and peripapillary vascular density (VD) changes in the pediatric group with optic disk drusen (ODD).

METHODS

Sixty eyes of 30 patients with buried ODD referred by the pediatric or neurology physicians to ophthalmology clinic with a preliminary diagnosis of papillary edema were included in this retrospective study. Sixty eyes of 30 healthy children were included as the control group. Thickness of RNFL (micrometer) and VD percentages (%) of the superior, inferior, nasal, and temporal quadrants of the peripapillary region of all cases were evaluated with optical coherence tomography angiography (OCT-A) device.

RESULTS

The study and control groups were homogeneous in terms of age and gender. VD values were significantly lower in the study group for all four quadrants, when compared to controls (p < 0.001, p < 0.001, p = 0.003, and p < 0.001, for inferior, superior, nasal, and temporal quadrants, respectively. For RFNL thickness measurements, a significant difference between groups was only evident for the nasal quadrant, where the study group had significantly higher nasal RFNL thickness (p = 0.001).

CONCLUSION

This study detected decreases in peripapillary VD values in all quadrants and peripapillary RNFL thickening in nasal quadrant in pediatric cases with buried drusen compared to healthy controls. Further studies are necessary to reveal the effects of drusen pathogenesis on optic nerve head perfusion and to understand the underlying mechanisms of related complications.